Abstract
Swedish fathers are largely involved in their infant’s care, and Sweden has a generous parental leave, with 2 months especially assigned for fathers. The prevalence of depressive symptoms postpartum for fathers appears to be similar as for mothers in Sweden. This study aimed to describe fathers’ experiences of the first year postpartum, when they showed depressive symptoms 3 to 6 months postpartum. Semistructured interviews with 19 fathers were conducted and analyzed with content analysis. The fathers experienced loss of control and powerlessness due to discrepancies between their expectations and the reality they met after birth. They found the everyday-life turbulent, with much stress and worries for the infant, conflicts between family and work, and lack of support in everyday life. In addition, the fathers struggled with impaired partner-relationship, losses, and contradictory messages from both the society and their partners. These findings indicate that the fathers had difficulties to balance the competing demands of family, work, and their own needs. Thus, it is important to identify fathers with depressive symptoms at the Child Health Care Centers and attend to fathers’ needs of support and acknowledge them as parents equal to mothers.
Introduction
Transition to parenthood may be challenging for both mothers and fathers, particularly if they experience depressive symptoms during the first postpartum year. In Sweden, there is an ambition to involve fathers early in infant care and increase gender equality between parents through political decisions and economic support (Premberg, Hellström, & Berg, 2008). Thus, Swedish men are strongly encouraged to participate in pregnancy, birth, and child care (Persson, Fridlund, Kvist, & Dykes, 2011). According to a parliamentary decision of 1979, all new parents should be offered support, education, and health information, individually or in group after birth at the Child Health Care Centers (CHCCs; Statens Offentliga Utredningar, 2008). In addition, Sweden has one of the world’s most generous parental leave; totally 480 days of which 2 months are assigned only to fathers. These two “father-months” constitute one of the efforts to increase the men’s share of parental leave (Försäkringskassan, 2011). Despite that, only 24.4% of the total numbers of parental benefit days 2012 were paid to fathers (Försäkringskassan, 2013).
Background
Prevalence and Risk Factors for Paternal Depressive Symptoms Postpartum
The first study to systematically examine depressive symptoms in new fathers was conducted by Ballard, Davis, Cullen, Mohan, and Dean (1994), which identified a prevalence of 9% self-reported depressive symptoms 6 weeks postpartum. Goodman (2004) reported in a literature review 10 years later that the prevalence of paternal depressive symptoms 1 year postpartum ranged from 10.1% to 28.6%. Additionally, among fathers whose partners experienced postpartum depression, the incidence of paternal depression was 24% to 50% during the first year, and maternal depression was identified as the strongest predictor of paternal postpartum depression (Goodman, 2004). In a recent meta-analysis, Paulson and Bazemore (2010) reviewed 43 studies from 16 countries and reported a prevalence of 10.4% during the perinatal period, that is, from the first trimester of pregnancy up to 1 year postpartum, with the highest rates of 25.6% reported 3 to 6 months postpartum. They also verified a positive correlation between depression in fathers and mothers. In Sweden, Bergström (2013) identified a prevalence of 10.3% among new Swedish first-time fathers 3 months postpartum. This is a similar prevalence of depressive symptoms as for Swedish new mothers, which is reported to be 11.1% at 2 months postpartum (Rubertsson, Wickberg, Gustavsson, & Rådestad, 2005).
Predictors reported for postpartum depression in fathers are their own history of depression (Areias, Kumar, Barros, & Figueiredo, 1996), discord in the marital relationship, poor relationship with their own parents (Matthey, Barnett, Ungerer, & Waters, 2000), and lack of support (Wee, Skouteris, Pier, Richardson, & Milgrom, 2011). Bergström (2013) reported that younger men, less than 29 years, had an increased risk for depressive symptoms after birth and that low educational level, low income, and financial worries were additional risk factors.
Differences Between Men and Women According to Depressive Symptoms
Twice as many women as men are diagnosed with depression in the general population (Addis, 2008). The reason for the higher prevalence of depressive symptoms in females is not known. However, a factor often referred to is that men express their feelings in different ways than women, for example, with anger attacks, affective rigidity, self-criticism, and alcohol and drug abuse (Winkler, Pjrek, & Heiden, 2004). Therefore, it has been suggested that depression in men can be “masked,” because it does not correspond to woman’s symptoms, and thus does not relate to the symptoms in the Diagnostic and Statistical Manual of Mental Disorders (DSM), leading to underdetection and underestimated rates in men (Addis, 2008). This was confirmed in a Swedish study by Danielsson and Johansson (2005), who reported that men and women formulated their experiences and understanding of being depressed in a gendered way, which might put depression in men at risk for underdetection.
Heifner (1997) concluded in a qualitative study that men were more likely to be depressed if they accepted rigid, traditional gender identity and roles, believed that acceptance of others is dependent on performance, lacked connectedness with others, had a hidden self, and felt out of control with no or few internal or external options. Thus, Heifner suggested that beliefs about being male and masculinity are challenged by the depression.
Consequences of Parents’ Depressive Symptoms on the Infant
Maternal depressive symptoms postpartum have been associated with emotional and behavioral problems in the infant, as well as delayed cognitive development and infant growth (Murray & Cooper, 1997; Nasreen, Nahar-Kabir, Forsell, & Edhborg, 2012). During recent years, researchers have reported that also the fathers’ depressive symptoms could affect the children’s development and health adversely, even after controlling for maternal depression (Cummings, George, Koss, & Davies, 2013). Ramchandani, Stein, Evans, O’Connor, and the ALSPAC study team (2005) identified in a large, population-based study that depressive symptoms in fathers, 8 weeks postpartum, were associated with an increased risk of emotional and behavioral problems in children and with conduct disorders in boys aged about 3.5 years. In a later study, Ramchandani et al. (2008) also reported an increased risk for psychiatric, behavioral, and conduct disorders as well as peer difficulties in children at the age of 7 years, if their fathers had been depressed in the pre- and postpartum periods. However, the research group concluded that the association between paternal depressive symptoms and child behavior was stronger in boys than girls. Moreover, those children whose fathers were more chronically depressed appeared to be at a higher risk. In a recently published study, Ramchandani et al. (2013) identified that disengaged interactions of fathers with their infants at 3 months postpartum, predicted behavioral problems in children.
Taken together, in general, men’s prevalence of depressive symptoms is only half of women’s (Addis, 2008). In Sweden, a recent study indicates that fathers have a similar prevalence of depressive symptoms postpartum as mothers (Bergström, 2013; Rubertsson et al., 2005). Since Swedish men are to a great extent involved in the birth and the care of their infants already from birth (Persson et al., 2011), the burden of responsibility might be too high and thus increase the risk of developing depressive symptoms in new Swedish fathers. Therefore, it is important to pay attention to fathers at the CHCC, particularly if the mothers also had been depressed, to identify and support the fathers to reduce their suffering and, in addition, to prevent the infants from adverse development and health. There are evidences that the infants’ development and health can be negatively influenced by paternal postnatal depression, also independently of maternal postnatal depression (Ramchandani et al., 2005; Ramchandani et al., 2008). Several qualitative studies have been conducted to describe new fathers’ transition to fatherhood (e.g., Draper, 2003; Nyström & Öhrling, 2004), but few studies have described depressed fathers’ experiences during the postpartum period with their own words. Thus, the current study intended to describe new fathers’ experiences the first year postpartum, when they reported depressive symptoms 3 to 6 months postpartum.
Method
Design
A descriptive, qualitative study was conducted, using inductive content analysis, to analyze the experiences of the first postpartum year for fathers with depressive symptoms. Qualitative content analysis is a method for systematic and rule-guided classification and description of text material, focusing on both manifest and latent contents (Burla et al., 2008). In a content analysis design, the researcher relies solely on available texts to answer a research question within the context as the researcher has chosen to read them, and through this it is possible to recognize meaning, symbolic qualities, and expressive contents in the texts (Krippendorff, 2013). This study is part of a larger, quantitative study about prevalence and interventions for postpartum depressive symptoms in fathers. Ethical approval was given by the Regional Ethics Committee at the Karolinska Institute for both the quantitative study and the qualitative study (Registration No. 2010/2001-31/4). The research team included a psychologist (LL) who could take care of depressive symptoms and refer to psychiatric specialist service if needed.
Participants
Participants in this qualitative study were selected purposely, that is, only fathers with depressive symptoms who had given consent to be part of an intervention study, from the larger, quantitative study. The quantitative study included all men in Stockholm who had become fathers in November-December 2010 and May-June 2011. These new fathers were sent questionnaires measuring depressive symptoms 3 to 4 months postpartum, and 3,656 fathers returned questionnaires. Of these fathers, 573 (15.7%) were identified with self-reported depressive symptoms 3 to 6 months postpartum, that is, scored 10 or more on the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987) and/or 13 or more on the Gotland Male Depression Scale (GMDS; Zierau, Bille, Rutz, & Bech, 2002). The EPDS has been validated for use in new fathers and the recommended cutoff point is 10/11 for men (Matthey, Barnett, Kavanagh, & Howie, 2001). Since it has been suggested that “male depression” might be expressed in different way than “female depression” (Addis, 2008), GMDS was used as a complement to EPDS to improve the recognition of depression in new fathers. GMDS has been validated in Sweden, and a score of 13 or more indicates possible depression (Zierau et al., 2002).
The fathers with signs of depression 3 to 6 months postpartum were randomized, either to an intervention group and offered nondirective counseling (N = 270), or to a control group and offered a self-help book based on Internet support for depressive symptoms (N = 275). Sixty-four fathers agreed to participate in the intervention study by accepting either the self-help book (N = 38) or nondirective counseling (N = 26). The first 30 of these 64 fathers with depressive symptoms were informed about the qualitative study in a letter and asked if they wanted to participate in an interview study after the intervention, to describe their experiences as fathers during the first postpartum year. Twenty-two of the 30 fathers gave their written consent to the interview, but three fathers could not be reached or did not have time when they were contacted for the interview. Thus, 19 fathers who showed signs of depression 3 to 6 months postpartum were interviewed when their infants were between 6 and 14 months old. For description of the participants, see Table 1.
Description of the Participants.
Note. EPDS = Edinburgh Postnatal Depression Scale; GMDS = Gotland Male Depression Scale.
Data Collection
Data were collected by semistructured interviews from June 2011 to September 2012. The fathers who had agreed to participate in the interview study were phoned by the first author (ME), informed about the interview, and were taken consecutively into the study. Since saturation was noted after the last interviews, no more fathers were contacted after the 19 fathers who had given consent and were available for interview. The fathers who were on parental leave at the time for the interview (N = 5) brought their infant along, but in other cases the interviews were conducted with the father alone. All interviews were conducted by the first author (ME) after the intervention (self-help book or nondirective counseling) and were based on an interview guide about the fathers’ experiences, from birth until the present time for the interview concerning (a) expectations, (b) everyday life with the infant, (c) work situation, (d) involvement in the infants’ care, (e) partner relationship, (f) social support, and (g) positive/negative aspects of becoming a father. The interviews were tape-recorded, lasted approximately 60 minutes, and were transcribed verbatim (in Swedish).
Data Analysis
Data were analyzed using qualitative content analysis, according to Graneheim and Lundman (2004), focusing on the latent content, meaning that the analysis also involves interpretations of the underlying meaning of the text. The 19 transcribed interviews with new fathers with depressive symptoms were used as units of analyses.
All transcripts were read through by the first author (ME) several times, and half of the transcripts, randomly assigned, were read by the last author (LL) to obtain an overview of the content. After a discussion of the overall sense of the text, two randomly assigned transcripts were independently analyzed by the first and last authors for validation. The content analysis began with identification of meaning units in the text. A meaning unit could be words, sentences, or paragraphs related to the research question. The meaning units were then condensed, which according to Graneheim and Lundman (2004) is a process of shortening the text, while still preserving the core content. The condensed meaning unit was labeled with a code, which summarizes its content. The independent coding between the two researchers was compared and discussed until agreement was reached and the beginning of a code scheme developed. The remaining transcripts were coded and additional codes were added by the first author (ME) to the code scheme when the text required. After that, the codes were compared based on differences and similarities and sorted into categories and subcategories. Creating categories is a core feature of qualitative content analysis, and a category is a group of content that shares a communality and should be exhaustive and mutually exclusive (Krippendorff, 2013). The tentative categories were developed by the first author (ME) and were then discussed between the first author (ME) and the last author (LL) and revised until agreement was reached about relevant codes in the respective categories. The underlying meaning, that is, the latent content, was formulated into a theme that is, the thread of the underlying meaning through the categories (Graneheim & Lundman, 2004). The main theme emerging was “Loss of control and powerlessness” explained by five categories (see Figure 1).
Presentations of the theme and categories emerged in the analysis.
Findings
The Main Theme: Loss of Control and Powerlessness
The fathers who showed depressive symptoms 3 to 6 months postpartum reported that they felt loss of control and powerlessness, due to lack of knowledge, uncertainty, feelings of insufficiency, and the burden of responsibility for the newborn child. They described the first months as “being in a bubble,” with feelings of being trapped, alienated, and isolated. One father described it “as a claustrophobic feeling of not being able to move” (F9).
The fathers felt alone and were afraid that something might happen to their infants. They were frustrated and felt not good enough, either at home or at work. One father described it as “always feeling elsewhere and that you don’t do your best” (F8), and another said “that he felt he has to be a superman” (F5). They experienced their lives as being filled with demands from the infant, work, and society, without any possibilities to control either the situation or their own time. One father described it as follows: “Dark thoughts that life is a treadmill I constantly run on” (F19). To manage everyday life they developed routines and waited for better times as strategies to get balance into life and hope for the future. They expressed it as follows: they had to “face out” (F17), to “ride out the first year” (F8), “keep on” (F19), and “to force themselves” (F4) through the first year and then it would be better. Some fathers had difficulties in remembering the first months; they just remembered them as a mess, without routines and sleep. The fathers explained their feelings of loss of control and powerlessness due to five categories: Discrepancy between expectations and reality, Turbulent everyday life with parental stress and lack of support, Changes in the partner relationship, Negative life events and sense of loss, and Contradictory messages about equality in parenthood from the society and the partner (Figure 1).
Discrepancy Between Expectations and Reality
The discrepancy between their expectations and the reality they met after the birth was a shock for the fathers. They had heard from friends and relatives that the first period with a new child could be hard, but they had not expected the reality after birth to be as intensive and hard as it turned out. Especially first-time fathers with depressive symptoms at 3 to 6 months stated that they did not expect that life would change so completely and that they were not prepared for the strong feelings they felt of responsibility. Although first-time fathers expected that the delivery would be difficult, they experienced the delivery more negatively than expected, even if it was considered as normal by the health care personnel.
Fathers who had children before had expectations that this birth should be easier than the first, but did not find their previous experiences as useful as they expected and one father concluded that he “forgot how difficult it is in the beginning” (F2). These fathers with children before had expected to work until birth, but when their partners got complications during pregnancy they had to stay at home with their elder children. This unexpected situation had a negative impact on the planning and preparation for their fatherhood, as well as causing stress in their work situation and contributed to their feelings of depression. Another unexpected situation was if an infant was born prematurely, or was ill or disabled, which complicated their life a long time after birth. One father, whose infant was born with a disability, said, “I had expected a normal delivery and a healthy infant after we had twins in week 23 the last time and just recovered from that experience” (F12). Another father with a premature infant, born in week 23, with a heart defect and many other medical problems, said, “It took time to adjust, but finally you have to realize that it is possible to live another life than you had expected to live with two healthy children” (F15). Some fathers with depressive symptoms stated that they did not feel anything for the infant at birth and did not find the birth as fantastic as they had expected it to be. The fathers also reported that they had not expected to be awake day and night due to the infants’ needs and crying in the beginning.
Turbulent Everyday Life With Parental Stress and Lack of Social Support
The fathers reported that life had entirely changed after birth. Their days were now filled with child care routines, planning, coordination, and negotiations to put everyday life together, and there were no opportunities for unplanned events or spontaneity in life. One father said, “There is no time for anything else than work and taking care of the infant, I feel like a robot with no choices or happiness in life” (F11).
The fathers found it fragmented to both work and be involved in the infants’ care as much as they wanted. They expressed feelings of not being able to perform as they were expected to do, neither at work nor at home, and they felt guilt toward their partners when they had to work too much. Some of the fathers had high work-related demands on themselves and tried to work as they did before birth, but realized soon that they could not prioritize work as much as they had done before. One “depressed” father said,
. . . and then I made the decision to say, that I am sorry, but I cannot do this work right now . . . so even though my boss and colleagues said we have no stand-in for you, I said, I cannot do it. I should have taken this stand sooner. (F15)
The fathers experienced not only stress from their workplace, they also experienced a lot of parental stress because of crying infants, growth problems, and illnesses in the infants. Most of all they complained about infants who did not want to sleep and/or those who wake up several times per night. They expressed feelings of guilt toward their partners, who took more responsibility for the infant during the nights, since most of the fathers were working after the 10 days’ parental leave in connection with the birth. Even if they tried to ease the load on their partners, they felt that they could not do so much. They reported that they lack sleep and they had tested several methods to get the infant to sleep better and did not find the CHCC particularly helpful with this major problem for the whole family. Possibilities of sleeping were considered as necessary by the fathers if life should succeed. “If you cannot sleep, everything will be hard, the relationship and the work” (F3).
Those fathers who were on parental leave felt alone, isolated, and worried that something would happen to the infant. One father said, “You cannot leave him . . . one cannot takes the eyes off him now . . . you are restricted in what you can do . . .” (F7). Another said, “Even if she plays a little while . . . and she seems to think that life is nice, you feel all the time that you cannot relax” (F9).
The fathers also reported a lack of help and support in everyday life, since their parents and parents-in-law did not live in the Stockholm area, or were dead, ill, or too old to be responsible alone for the infant. Some of the fathers said that they had social support available but did not utilize it. Instead they said they rather kept their needs and problems to themselves. One father said, “I am not the one who pushes my problems onto others” (F12), and another said, “Everybody has enough problems of their own” (F13).
The fathers also reported conflicts between their family and their partner and between themselves and their own families, which complicated social support and daily life. Some fathers experienced problems in everyday life, due to the fact that they could only leave their older children at day care 15 hours/week, which was difficult, both for the older children and for the parent on leave. Several of the fathers reported that also their partners were depressed, which increased their workload at home and their need for social support.
Changes in the Partner Relationship
All the interviewed fathers reported changes in the relationship with their partners after the birth, and most of them also reported impaired or poor relationship with the partner. Several of the fathers said that they had thought of divorce and that they stayed together only for the infants’ sake. The fathers believed that their relationship to the partner was negatively influenced by all the stress and that they had to plan, coordinate, and negotiate all the time.
They experienced more conflicts, arguments, irritations, and frustrations between themselves and their partners than before. The relationship became strained, small things became big, they misunderstood each other, and many problems remained unsolved. The fathers experienced that they did not communicate with each other as they had done before and when they communicated they often talked through the infant.
Particularly fathers with a short relationship, or a poor relationship to their partner already before the infants’ birth, were worried that their relationship may not last. One father said, “The relationship is the hardest . . . when the relationship becomes difficult and strenuous; you have nothing to fall back on” (F7). Fathers with a long relationship also experienced more conflicts, irritations, and unfinished communications, but they were more positive about the partner relationship. One father said, “The relationship breaks off somehow and I was not prepared for that . . .” (F8). The fathers experienced that love disappeared and they often referred to the impairment of the relationship to the partner as an explanation of their depressed mood.
Negative Life Events and Sense of Loss
Another explanation for the depressed mood, expressed by the fathers, was that many negative life events happened during a short period close to the birth. The fathers reported, for example, that their own fathers died, or that close relatives had become seriously ill. Many of them had changed work, moved to bigger apartments or houses, and the fathers felt the economic responsibility as heavier than before.
For those families who experienced complications during the birth or with the infant, life became more difficult than they were prepared for. These fathers felt that “everything is falling apart” (F13) or that there is “no end of the misery” (F12). The fathers who had got a disabled or ill infant mourned the healthy infant they had expected; they mourned the playmate for the older siblings and that life had not been as expected.
The fathers said that they had to sacrifice all their interests and social life to the priority of the children. They missed leisure time, time to be together with their partner, and to see friends. They missed the work and work-mates when they were on parental leave, and the infant and family when they were working.
The main adjustment for us was to suddenly have very little own time, and if you take time it required something of the other . . . it intrudes on everything, social life, exercise . . . suddenly there was no time left. (F5)
Contradictory Messages About Equality in Parenthood From the Society and the Partner
The fathers reported that they wanted to be available as fathers and completely involved in the care and life of their infants. Most of the fathers had decided, already before birth, that they wanted to be on long parental leave and that they wanted equal status in parenthood as the mother: sharing both the household work and the care of the infant. Equality in parenthood and the father’s engagement in the infant’s care were also important for their partners, since all, except for one mother, planned to start working after their parental leave. Several of the fathers had shared or planned to share the parental leave equally with their partners. However, already at birth, they did not find it easy to be an equal parent and expressed feelings of being excluded as a father and not seen by the society as having the same value as the mother.
Thus, the fathers perceived that the society gave them contradictory messages about equality in parenthood, since the mothers always were prioritized and seen as the head parent by society. The fathers expressed that the role of the father is poorly defined. Since the traditional role as a breadwinner no longer exists, fathers today serve as factotum, whose role is exchangeable, and thus, fathers are not seen as important as mothers. One father said, “It is not natural how the role is to be played . . . I see myself as a father, but many of my friends are not yet there” (F15). Even those fathers who had shared the parental leave equally felt that the mothers’ opinions were seen as more important than the father’s by the health care personal and the society. They also felt that their infants preferred the mother instead of them if she was available. This gave them a feeling of being subordinated to their partner as a parent. One father said,
We have shared (household tasks) even if I have done most of them . . . then I think . . . that I also feel that it is still the woman who is the head parent somehow. . . . Fathers should not whine, nor be in the center . . . they should be happy because they had become fathers and can take parental leave. (F9)
When the fathers were on parental leave, they found it difficult to make contact with mothers, who still constitute the majority of parents on leave. Thus, they felt alone, isolated when they were home with their children. They also experienced that people, and some of their friends, reacted negatively to them—as if they did not find it natural that fathers should be home with their infants for a longer time.
Not only the society gave contradictory messages also their partners did. Although they had both agreed to share the care of the infant before birth, the fathers experienced that their partners found it difficult to actually live up to this agreement. The fathers expressed that they always had to do as their partner did and comply with what the partner told them to do regarding the care of the infant. They felt that their partner evaluated and criticized them when they cared for the infant, and experienced that they were not allowed to be fathers in their own way. One father said, “What makes me so angry is that I feel that I am less worth and that I am a bad parent” (F6). Another said,
There have been tendencies for her to see me as non-present or a non-equal parent or somebody not taking responsibility. That is not in line with reality, it is in line with some kind of expectation of how it is. (F17)
Discussion
The overall purpose of the current, qualitative study was to get a description of fathers’ experiences of depressive symptoms in the postpartum period, in their own words, as the literature suggests that men express their depressive feelings in different ways than women (Danielsson & Johansson, 2005; Winkler et al., 2004). Mothers with depressive symptoms are today in Sweden mostly captured by the CHCC routine screening with the EPDS, and are offered counseling (active listening), which has been demonstrated to have an effect on Swedish mothers (Wickberg & Hwang, 1996). However, we do not know if fathers with depressive symptoms postpartum have the same needs as mothers or are helped with the same support. Thus, it is important to listen to new fathers with depressive symptoms, to find out their needs, wishes, and if and how these fathers could be offered relevant support or treatment by the CHCC.
Loss of Control and Powerlessness
The transition to fatherhood has been described as a period of adaptation, with life changes and stress (St John, Cameron, & McVeigh, 2005), and as living in a new and overwhelming world (Nyström & Öhrling, 2004). St John et al. (2005) investigated 18 fathers’ experiences during the first 6 to 12 weeks postpartum and concluded that the fathers felt the expanding role of fatherhood as challenging and as a time of changes. To balance the competing demands from family and work in everyday life, they were required to reflect, reprioritize, and make choices. In our study, the fathers, on top of all the stresses related to being a father, also experienced depressive symptoms, reported loss of control and powerlessness, indicating difficulties in this act of balancing and to deal with stresses, feelings, and demands. The fathers with depressive symptoms described that they had no time to reflect over their situation, and they found it difficult to cope with all conflicting demands and feelings of not being good enough, either at work or as a parent. St. John et al. (2005) also described that the fathers in their study met the conflicting priorities in their life by developing routines, negotiating with their partners, and reprioritizing to find time of their own. In the current study, the fathers also saw routines as a strategy to get balance back into life, and they also said that their hope for the future was to wait for better times. This passivity, inability to prioritize, and deal with the situation might be an outcome of their depressive symptoms.
The fathers also complained over lack of sleep and meant that it was necessary to sleep if they should be able to manage everyday life. Mellor and St. John (2012) confirmed that fatigue and lack of sleep are common experiences for fathers with babies, and that these problems increase from 6 to 12 weeks. Frequency rates of fatigue reported for the general working population range from 20% to 30%, whereas Mellor and St. John (2012) reported frequencies of 65% at 6 weeks and 75% at 12 weeks of fatigue in new fathers. The authors argued that workloads for fathers might need to be reduced during the first 12 weeks, since they did not have any possibility to recover from fatigue due to interrupted and lack of sleep (Mellor & St. John, 2012). This is important for policy makers to pay attention to, since too little sleep for new fathers may lead to mistakes both at work and at home (Mellor & St John, 2012), and strive toward a reduced workload for fathers the first months postpartum. In addition, CHCC nurses have to take the infants’ sleep problems seriously and together with the parents find out solutions.
Changes in the Relationship
The fathers experienced that the relationship with their partner deteriorated after the child birth. They reported about conflicts, arguments, and misunderstandings between them and their partners. Condon (2006) suggests that the communication breakdown, as many of the fathers described in this study, is common in families with a postpartum depressed mother, and that this together with other stresses postpartum may lead to separation. This was applicable also in families where the fathers show depressive symptoms postpartum; especially fathers with new partner relationships talked about separation as the only way out. Several epidemiological researchers have reported that having a poor relationship with the partner, or no romantic relationship, is one of the main risk factors in developing depressive symptoms in both mothers (O’Hara & Swain, 1996) and fathers (Ramchandani et al., 2011; Wee et al., 2011). Deater-Deckard, Pickering, Dunn, and Golding (1998) revealed that men in stepfamilies, and those whose partners were single mothers before they met, had higher levels of depressive symptoms after birth than men in traditional families. In the current study, two of the “depressed” fathers had children in a previous relationship, with shared custody. These fathers expressed much concern about their relationship and recognized the same feeling in the current relationship as they had felt in the previous relationship, which had resulted in separation.
In addition, there is evidence that marital conflicts mediate the well-known associations between both maternal and paternal depression postpartum and in child behavior, such as emotional and conduct difficulties (Cummings, Keller, & Davies, 2005; Hanington, Heron, Stein, & Ramchandani, 2011; Ramchandani et al., 2011). Thus, the impact of parental depressive symptoms on the partner relationship has to be paid attention to at the CHCC, and relevant support has to be offered to prevent negative outcomes for the infants, such as family counseling, individually or in group. Nearly all the fathers with depressive symptoms expressed serious concerns about their deteriorated relationship with their partner. Consistent with this, a recent study reported that depressive symptoms among parents are associated with marital separation in Sweden (Kerstis et al., 2014).
Association Between Maternal and Paternal Depression
It has been suggested that the greatest risk factor for postpartum paternal depression is to have a depressed partner (Goodman, 2004; Wee et al., 2011). If one of the parents is depressed, the other has an increased risk of developing depressive symptoms (Paulson & Bazemore, 2010), and children with two depressed parents are at significantly greater risk for poor developmental outcomes, compared with children with only one depressed parent (Brennan, Hammen, Katz, & Le Brocque, 2002).
Several fathers in the current study reported that their partners were or had been depressed during pregnancy and/or postpartum. Living with a depressed partner after birth has been described, from nondepressed men’s perspective by Meighan, Davies, Thomas, and Droppleman (1999) as a major disruption in life and in the partner relationship. Loss of control was one of the themes describing the experience of having a female partner with postpartum depression and the nondepressed fathers described their world as being totally unpredictable and out of control. This resulted in feelings of helplessness, frustration, aloneness, fear, and anxiety. These results are similar to what the fathers in the current study expressed as their experiences and could thus indicate that some of the fathers might have developed depressive symptoms due to their situation living with a depressed partner.
Contradictory Messages About Equality in Parenthood
The fathers in the current study said they had a desire to be involved, available fathers, and wanted to be an equal parent. However, already during the birth they found that this was not so easy and the fathers expressed feelings of being excluded as a parent. These feelings are supported by Thomas, Bonér, and Hildingsson (2011), who reported that there is evidence that Swedish antenatal care only considered the father to be a support person for the mother. In the current study, the fathers reported that they at the delivery often felt invisible and excluded as a parent, particularly if their partners had complicated deliveries. This was supported by Lindberg and Engström (2013), who reported that new fathers in Sweden struggled to be recognized by care staff as partners in the family at the delivery. During the postpartum period, Massoudi, Wickberg, and Hwang (2011) revealed that nurses at Swedish CHCC to some extent still favor mothers, although the Swedish parliament already in 1979 recommended them to offer support, education, and information related to child birth to both mothers and fathers. Massoudi et al. (2011) also reported that many of the nurses, particularly over the age of 50 years, had a traditional view on mothers’ versus fathers’ instinctive competencies in child care.
Although intending to be an equal parent, the fathers felt deviant in their father role, and furthermore, they reported that others in their environment also saw them as deviant fathers, when they acted as an equal parent. Since the Swedish society politically strives toward equality in parenthood, the fathers experienced inconsistent messages from the society and the health care services. This could also indicate that the fathers in their mind had not adopted the father role they wanted and intended to do. Heifner (1997) revealed that men who became depressed often had traditionally, stereotyped gender role identities, such as that a man should be strong, successful, in control, and capable of handling problems without help. Thus, these fathers who felt depressed postpartum, might have the “hegemonic masculinity” as an ideal for how men should be. This ideal is characterized by emotional control and lack of vulnerability (Emslie, Ridge, Ziebland, & Hunt, 2006) and thus incompatible with their feelings of lack of control and powerlessness. Though not fully expressed, this masculinity ideal might at least partly be present among the fathers in the current study, as they felt deviant and unusual when they acted like the father they wanted to be and took a long parental leave. They also expressed a reluctance to ask for help and that they kept their feelings to themselves. This could be explained by the Gendering Responding Framework assuming that gender norms affect how men and women response to negative affect (Addis, 2008). According to Nolen-Hoeksema and Jackson (2001), women were more likely to ruminate and seek social support in response to being upset, while men were more likely to keep their feelings to themselves, using alcohol, swearing, or engaging in a sport in response to be upset. Thus, the “hegemonic masculinity” ideal seems to challenge both the depressive symptoms and the “new” father role.
The fathers also expressed that they got contradictory messages from their partner about sharing the care of the infant and that she could be a barrier to participation in the infant’s care. As the mother is often the first carer, she learns earlier and probably becomes better in reading the infant’s needs and thus develops smooth ways for handling the infant and how to comfort the infant. Thus, the mothers wanted the fathers to do as they did, and the fathers felt evaluated by their partners and that they could not be the kind of father that they themselves wanted to be. Thomas et al. (2011) reported in their study that fathers who experienced difficulties in parenthood often did not receive support from their partners after birth; and Buist, Morse, and Durkin (2003) identified that feelings of being controlled by ones’ partner was predictive of paternal depression postpartum.
Limitations
Some limitations of this study are worth mentioning. The new fathers’ depressive symptoms are self-reported at 3 to 6 months postpartum, and the fathers’ moods at the time of the interview are not known. Some of the fathers had gone through counseling, and some received a self-help book. The reason for having the intervention before the interview was partly ethical. With knowledge about which fathers have depressive symptoms, it was considered important to offer them some help. The other, more scientific reason was that a qualitative interview might have an intervention effect in itself. For the credibility of the current study results, this could mean that the fathers were more reflective in the interview than if they had been interviewed before the intervention. In this way, the credibility may have increased. However, the fathers’ reporting were retrospective to some extent and thus could be biased due to recall bias. Moreover, in some cases the fathers did not have depressive symptoms at the time of the interview, the infant had been older, and therefore a more positive picture could have appeared than if the interviews were performed before the intervention.
Since there is some evidence that men express depressive feelings in a different way than women, two different kinds of screening instruments (EPDS and GMDS) were used to measure the fathers’ depressive symptoms. The EPDS is developed and validated for postpartum use, but has been suggested to pick up more “distressed” symptoms as worry and unhappiness than depression in Swedish men (Massoudi, Hwang, & Wickberg, 2013). The GMDS is suggested to pick up “male” depression and is validated in Swedish men. Fourteen fathers reported high levels on the GMDS and half of the fathers scored high on both scales, which thus increases the credibility that the fathers really showed depressive symptoms at the measurement.
Another limitation could be the sampling, since it was not from the beginning planned for reaching saturation. Most of the fathers had a university degree, all lived in Stockholm, and thus were rather homogenous socially. Therefore, the results might only be transferable to new, urban fathers with depressive symptom, who are relatively highly educated and motivated enough to take part in an intervention. For the validation of the analysis, two of the researchers (ME, LL) have discussed the emerging results several times and quotations have been used to enhance the credibility of the interpreting in the analysis. Despite this, it is possible that the interpretations could give a skewed picture and that some interpretations might have been paid more attention than others.
Conclusion
In this study, it is reported that new fathers with depressive symptoms, 3 to 6 months postpartum, felt loss of control and powerlessness after birth, indicating that they were unable to balance the competing demands of family, work, and their own needs and experienced conflicting messages from both the society and their partners. Men in Sweden are encouraged to be involved in the process of pregnancy, birth, and infant care after birth. However, instead of being involved, the fathers in this study experienced themselves as invisible and excluded as parents. Therefore, fathers are entitled to assume a higher profile and be considered as equally valuable parents as the mother. Fathers with depressive symptoms have to be identified by health personnel at the CHCC as well as mothers and given adequate help and support to meet the challenge of new fatherhood and changed partner relationship, to prevent emotional, behavioral, and conduct disturbances in their children. Further research could be performed on clinical approaches of offering fathers own visits to the CHCC for support of their own needs. Another research question may be whether the similar experiences and prevalence between men and women may be due to differences between urban and rural areas.
Footnotes
Acknowledgements
We thank the participating fathers for their invaluable contributions to the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Public Health Grant Stockholm County Council (Registration No. 2010/2001-31/4).